| NPI | 1922458892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: UT 13253486-1235) |
| Additional Taxonomies | 2086S0129X (Licence: MO 2022046851) |
| 2086S0129X (Licence: AZ 62608) | |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2026-06-17 |