| NPI | 1760726418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX S1034) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 1174887624) |
| 208600000X Surgery (Licence: MO 2018025701) | |
| Enumeration Date | 2012-11-19 |
| Last Update Date | 2019-08-05 |