| NPI | 1669482154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: WA MD60539899) |
| Additional Taxonomies | 2086S0129X (Licence: MN 49021) |
| 2086S0129X (Licence: MT 51984) | |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2021-05-18 |