| NPI | 1164164521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 208D00000X General Practice (Licence: AZ 74393) |
| 208100000X Physical Medicine & Rehabilitation (Licence: AZ 74393) | |
| Enumeration Date | 2022-04-07 |
| Last Update Date | 2026-06-03 |