| NPI | 1548214836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: FL ME154816) |
| Additional Taxonomies | 2085R0001X (Licence: NJ 25MA06683700) |
| 2085R0001X (Licence: NY 2093751) | |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2026-05-06 |