| NPI | 1760809123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: TX T5289) |
| Additional Taxonomies | 208600000X Surgery (Licence: VA 0101260554) |
| 208600000X Surgery (Licence: CO DR.0068147) | |
| 208D00000X General Practice (Licence: VA 0101260554) | |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2025-03-05 |