| NPI | 1972890564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MI 4301501095) |
| Additional Taxonomies | 208600000X Surgery (Licence: VA 0116023851) |
| 208600000X Surgery (Licence: MO 2016011008) | |
| Enumeration Date | 2011-07-01 |
| Last Update Date | 2021-04-28 |