| NPI | 1407812217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: FL ME127558) |
| Additional Taxonomies | 2085R0001X (Licence: LA 014266) |
| 2085R0001X (Licence: WA MD60651668) | |
| 2085R0001X (Licence: OR MD173309) | |
| Enumeration Date | 2006-04-21 |
| Last Update Date | 2019-07-16 |