| NPI | 1972545622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: WI 34121) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: WI 34121) |
| Enumeration Date | 2006-06-10 |
| Last Update Date | 2025-08-27 |