| NPI | 1306221916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: FL ME172814) |
| Additional Taxonomies | 2085R0001X (Licence: NY P96803) |
| 2085R0001X (Licence: IN 01077124A) | |
| 2085R0001X (Licence: OH 35.138513) | |
| Enumeration Date | 2015-07-24 |
| Last Update Date | 2025-06-03 |