| NPI | 1801197447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: FL ME111651) |
| Additional Taxonomies | 208600000X Surgery (Licence: NJ 25MA08860100) |
| Enumeration Date | 2010-11-13 |
| Last Update Date | 2012-01-06 |