| NPI | 1700306636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208C00000X Colon & Rectal Surgery (Licence: KY 05517) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 5101023538) |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2023-08-09 |