| NPI | 1770591562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: OH 35.0575510) |
| Additional Taxonomies | 2086S0129X (Licence: IA 37403) |
| 2086S0129X (Licence: HI MD-20852) | |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2025-04-30 |