| NPI | 1215930953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: NY A152185) |
| Additional Taxonomies | 225400000X Rehabilitation Practitioner (Licence: NY A152185) |
| Enumeration Date | 2005-05-26 |
| Last Update Date | 2015-04-22 |