| NPI | 1912107640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: GA 69941) |
| Additional Taxonomies | 208600000X Surgery (Licence: SC 1132) |
| 208600000X Surgery (Licence: PA OT 010413) | |
| 202K00000X (Licence: SC 1132) | |
| Enumeration Date | 2007-07-20 |
| Last Update Date | 2019-11-08 |