| NPI | 1710246053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX S9208) |
| Additional Taxonomies | 208600000X Surgery (Licence: NM MD2020-0636) |
| Enumeration Date | 2012-05-07 |
| Last Update Date | 2025-08-29 |