| NPI | 1053676049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: TX T4104) |
| Additional Taxonomies | 2086S0129X (Licence: MO 2022011041) |
| 2086S0129X (Licence: WY 16292A) | |
| 2086S0129X (Licence: AZ 59800) | |
| Enumeration Date | 2012-07-06 |
| Last Update Date | 2025-04-16 |