| NPI | 1699087239 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX S4395) |
| Additional Taxonomies | 208600000X Surgery (Licence: WY 13768A) |
| 208D00000X General Practice (Licence: GA 067938) | |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2025-10-07 |