| NPI | 1750796975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MO 2019024766) |
| Additional Taxonomies | 208600000X Surgery (Licence: KS 04-42287) |
| Enumeration Date | 2014-06-26 |
| Last Update Date | 2026-08-21 |