| NPI | 1770565012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: VA 0101052178) |
| Additional Taxonomies | 174400000X Specialist (Licence: VA 19851) |
| 174400000X Specialist (Licence: MD D43177) | |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2019-10-22 |