| NPI | 1215469507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: VA 0102206764) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-03-28 |
| Last Update Date | 2021-09-22 |