| NPI | 1417161704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: PA 425112) |
| Additional Taxonomies | 2085R0001X (Licence: NM MD2023-1495) |
| 2085R0001X (Licence: AZ 36390) | |
| 2085R0001X (Licence: NY 327337) | |
| 2085R0001X (Licence: CA 110561) | |
| 2085R0001X (Licence: NV 23276) | |
| 2085R0001X (Licence: CO CDR.0002379) | |
| 2085R0001X (Licence: PA MD425112) | |
| Enumeration Date | 2007-05-09 |
| Last Update Date | 2025-07-08 |