| NPI | 1295761898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: NM 86-136) |
| Additional Taxonomies | 2085R0001X (Licence: AZ 21749) |
| 2085R0001X (Licence: TX J5501) | |
| Enumeration Date | 2006-06-24 |
| Last Update Date | 2016-08-17 |