| NPI | 1760897367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: KS 04-44578) |
| Additional Taxonomies | 2086S0129X (Licence: MO 2025031338) |
| 2086S0129X (Licence: MN 65192) | |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2025-09-10 |