| NPI | 1215291398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084N0400X Psychiatry & Neurology, Neurology (Licence: KY 49966) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2012-07-03 |
| Last Update Date | 2017-04-20 |