| NPI | 1720092471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: GA 060940) |
| Additional Taxonomies | 208600000X Surgery (Licence: NC 2004-00150) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2023-01-10 |