| NPI | 1164575031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208VP0000X (Licence: PA MD064157L) |
| Additional Taxonomies | 208VP0000X (Licence: IN 01047998) |
| 208VP0000X (Licence: OH 35062207) | |
| 208VP0000X (Licence: MI 044463) | |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2007-07-08 |