| NPI | 1467768259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171W00000X Contractor (Licence: PA PT 019107) |
| Additional Taxonomies | 171W00000X Contractor (Licence: NY PT 028231-1) |
| Enumeration Date | 2010-08-31 |
| Last Update Date | 2010-08-31 |