| NPI | 1922455146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: WY 18666A) |
| Additional Taxonomies | 2086S0129X (Licence: OH 35.142390) |
| 208600000X Surgery (Licence: NY 311290) | |
| 2086S0129X (Licence: PA MD480977) | |
| 2086S0129X (Licence: ID 7061377) | |
| 2086S0129X (Licence: VA 0101285795) | |
| Enumeration Date | 2016-05-17 |
| Last Update Date | 2025-09-10 |