| NPI | 1912469628 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 207Y00000X Otolaryngology (Licence: TX V1086) | 
| Additional Taxonomies | 207YS0123X Otolaryngology, Facial Plastic Surgery (Licence: TX V1086) | 
| Enumeration Date | 2019-04-02 | 
| Last Update Date | 2025-10-06 |