| NPI | 1487058285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 111NR0400X (Licence: TX 15347) |
| Additional Taxonomies | 111NR0400X (Licence: OH 4545) |
| 111NR0400X (Licence: MI 2301010832) | |
| Enumeration Date | 2014-10-22 |
| Last Update Date | 2023-08-25 |