| NPI | 1760640411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD 60179569) |
| Additional Taxonomies | 208600000X Surgery (Licence: MO 2010020700) |
| Enumeration Date | 2008-05-29 |
| Last Update Date | 2021-06-14 |