| NPI | 1255359956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: FL ME125782) |
| Additional Taxonomies | 2085R0001X (Licence: ND 6730) |
| 2085R0001X (Licence: MN 44163) | |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2026-05-04 |