| NPI | 1912032962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WA MD61652294) |
| Additional Taxonomies | 208600000X Surgery (Licence: CA A75333) |
| Enumeration Date | 2007-02-22 |
| Last Update Date | 2026-05-21 |