| NPI | 1194728675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: WA MD61588028) |
| Additional Taxonomies | 2085R0001X (Licence: KY 48604) |
| 2085R0001X (Licence: KY TP591) | |
| 2085R0001X (Licence: AR E-2774) | |
| 2085R0001X (Licence: OH 35C.001746) | |
| 2085R0001X (Licence: MS 17137) | |
| Enumeration Date | 2005-05-27 |
| Last Update Date | 2025-10-15 |