| NPI | 1205897808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: NJ 25MA09102200) |
| Additional Taxonomies | 2085R0001X (Licence: PA MD030514E) |
| 2085R0001X (Licence: MD D0067927) | |
| Enumeration Date | 2006-03-31 |
| Last Update Date | 2025-01-22 |