| NPI | 1134396351 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: PA MD492236) |
| Additional Taxonomies | 2085R0001X (Licence: AZ 7786) |
| 2085R0001X (Licence: NH 35317) | |
| 2085R0001X (Licence: OH 35C.002860) | |
| 2085R0001X (Licence: NY 283635) | |
| 2085R0001X (Licence: VT 042.0018820) | |
| 2085R0001X (Licence: FL ME164227) | |
| 2085R0001X (Licence: TX V9773) | |
| 2085R0001X (Licence: IL 036.175974) | |
| 2085R0001X (Licence: NJ 25MA10674200) | |
| Enumeration Date | 2008-05-15 |
| Last Update Date | 2025-12-04 |