| NPI | 1063916484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: WA OP61176060) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: WA OP61176060) |
| 207Q00000X Family Medicine (Licence: WA OP61176060) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2024-02-08 |