| NPI | 1689700494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208200000X Plastic Surgery (Licence: FL ME75895) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: FL 75895) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2009-02-10 |