| NPI | 1811302573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MO 2017010598) |
| Additional Taxonomies | 208C00000X Colon & Rectal Surgery (Licence: MI 4301508891) |
| Enumeration Date | 2014-06-21 |
| Last Update Date | 2026-01-30 |