| NPI | 1790212967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: KY TP509) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MT213395) |
| 208600000X Surgery (Licence: WI 82965) | |
| Enumeration Date | 2017-05-17 |
| Last Update Date | 2025-07-16 |