| NPI | 1851492003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: UT 12568775-1205) |
| Additional Taxonomies | 2085R0001X (Licence: MO 2007029607) |
| 2085R0001X (Licence: IN 01070213A) | |
| 2085R0001X (Licence: OH 35093149) | |
| 2085R0001X (Licence: KY 42433) | |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2022-06-20 |