| NPI | 1114912516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2088P0231X (Licence: TN MD0000012874) |
| Additional Taxonomies | 174400000X Specialist (Licence: TN 12874) |
| 2088P0231X (Licence: FL ME130273) | |
| Enumeration Date | 2005-09-13 |
| Last Update Date | 2018-05-02 |