| NPI | 1700134830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: FL OS22932) |
| Additional Taxonomies | 2086S0129X (Licence: CA 20A14549) |
| 208600000X Surgery (Licence: CA 20A14549) | |
| Enumeration Date | 2012-08-21 |
| Last Update Date | 2026-02-19 |