| NPI | 1104965698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: OH PTA .03673) |
| Additional Taxonomies | 174400000X Specialist (Licence: OH LMT 33. 009335) |
| Enumeration Date | 2007-02-05 |
| Last Update Date | 2013-04-01 |