| NPI | 1972066397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208200000X Plastic Surgery (Licence: KY 62108) |
| Additional Taxonomies | 208200000X Plastic Surgery (Licence: NY 328018-01) |
| 208200000X Plastic Surgery (Licence: OH 35.153304) | |
| 208200000X Plastic Surgery (Licence: VA 0101289109) | |
| Enumeration Date | 2019-04-11 |
| Last Update Date | 2026-09-23 |