| NPI | 1629262621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: MO 2025011251) |
| Additional Taxonomies | 174400000X Specialist (Licence: AR e4793) |
| 2086S0129X (Licence: TX N6541) | |
| Enumeration Date | 2007-09-02 |
| Last Update Date | 2025-05-28 |