| NPI | 1093793655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: OH 35.154069) |
| Additional Taxonomies | 2085R0001X (Licence: MD D0076765) |
| 2085R0001X (Licence: PA MD049791L) | |
| 2085R0001X (Licence: NY NY183250) | |
| Enumeration Date | 2006-01-04 |
| Last Update Date | 2026-07-22 |