| NPI | 1649405028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: KY 54791) |
| Additional Taxonomies | 2085R0001X (Licence: NY 2628841) |
| 2085R0001X (Licence: TX U3134) | |
| 2085R0001X (Licence: PA MD464262) | |
| 2085R0001X (Licence: AL 32717) | |
| Enumeration Date | 2009-05-28 |
| Last Update Date | 2023-10-17 |