| NPI | 1366421562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: LA MD.05311R) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: LA 05311R) |
| 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) | |
| Enumeration Date | 2006-01-16 |
| Last Update Date | 2021-06-30 |