| NPI | 1750332292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: NY 226271-1) |
| Additional Taxonomies | 2085R0001X (Licence: NJ MA62363) |
| 2085R0001X (Licence: LA MD.207369) | |
| 2085R0001X (Licence: TX W2057) | |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2025-12-04 |