| NPI | 1861923955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NJ 25MB11832400) |
| Additional Taxonomies | 208600000X Surgery (Licence: MI 5101026565) |
| Enumeration Date | 2017-03-21 |
| Last Update Date | 2023-08-10 |