| NPI | 1396864047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: FL ME92965) |
| Additional Taxonomies | 2085R0001X (Licence: GA 055475) |
| 2085R0001X (Licence: WI 23932-020) | |
| 2085R0001X (Licence: TN MD40229) | |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2007-07-08 |