| NPI | 1518425321 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: OR DO223510) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2019-03-11 | 
| Last Update Date | 2025-06-27 |