| NPI | 1609074632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 2081P2900X Physical Medicine & Rehabilitation, Pain Medicine (Licence: CA A121953) |
| 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: VA 0101245601) | |
| Enumeration Date | 2007-07-11 |
| Last Update Date | 2020-09-22 |