| NPI | 1194952911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: TX S3284) |
| Additional Taxonomies | 2086S0129X (Licence: WA MD70029598) |
| 2086S0129X (Licence: OR MD218542) | |
| 2086S0129X (Licence: NY 265297) | |
| Enumeration Date | 2009-06-19 |
| Last Update Date | 2025-10-24 |