| NPI | 1063701217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: UT 5585387-1204) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: ID O-0868) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-03-28 |
| Last Update Date | 2021-03-15 |