| NPI | 1992201867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: CA A164774) |
| Additional Taxonomies | 208600000X Surgery (Licence: NC 2025-00357) |
| Enumeration Date | 2018-04-01 |
| Last Update Date | 2026-08-31 |