| NPI | 1972604197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: NY 125447) |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: NY 1254471) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2015-07-09 |