| NPI | 1578564613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: NY 333322) |
| Additional Taxonomies | 2085R0001X (Licence: KY 43854) |
| 2085R0001X (Licence: PA MD038569Y) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2025-09-29 |