| NPI | 1053574665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: VA 0101247609) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2081P0301X Physical Medicine & Rehabilitation, Brain Injury Medicine (Licence: VA 0101247609) | |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2025-07-11 |