| NPI | 1063033983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: TX V6719) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: SC 86588) | |
| Enumeration Date | 2020-05-01 |
| Last Update Date | 2025-05-02 |