| NPI | 1134689979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: PA OS021013) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207Q00000X Family Medicine (Licence: PA OT020104) | |
| Enumeration Date | 2019-03-20 |
| Last Update Date | 2023-09-27 |