| NPI | 1619355906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2086S0129X (Licence: GA 87001) |
| Additional Taxonomies | 2086S0129X (Licence: PA MT208212) |
| 2086S0129X (Licence: SC 87692) | |
| Enumeration Date | 2015-05-07 |
| Last Update Date | 2025-04-11 |