| NPI | 1255518734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: CO DR.00968898) |
| Additional Taxonomies | 2085R0001X (Licence: WV 27345) |
| 2085R0001X (Licence: SC 36269) | |
| Enumeration Date | 2008-01-27 |
| Last Update Date | 2022-07-01 |