| NPI | 1861738189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0001X (Licence: UT 10124565-1205) |
| Additional Taxonomies | 2085R0001X (Licence: TX AU3354177) |
| 2085R0001X (Licence: NC 2015-00676) | |
| 2085R0001X (Licence: SC 38030) | |
| Enumeration Date | 2012-12-13 |
| Last Update Date | 2017-01-12 |