| NPI | 1225116445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0131X (Licence: WA 60015889) |
| Additional Taxonomies | 213ES0131X (Licence: OH 2280) |
| 213ES0131X (Licence: MA 1755) | |
| 213ES0131X (Licence: NY N3760) | |
| Enumeration Date | 2006-11-02 |
| Last Update Date | 2016-03-02 |