| NPI | 1790908796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: FL ME170118) |
| Additional Taxonomies | 2085R0001X (Licence: AL 29354) |
| 2085R0001X (Licence: NC 2007-01477) | |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2024-10-30 |