| NPI | 1295933448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: FL ME138301) |
| Additional Taxonomies | 2086S0129X (Licence: TX S3565) |
| 2086S0129X (Licence: OH 35.096964) | |
| Enumeration Date | 2007-07-10 |
| Last Update Date | 2026-02-13 |