| NPI | 1396196101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: FL ME141148) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: GA 86393) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-06-23 |
| Last Update Date | 2021-08-31 |