| NPI | 1609300797 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208VP0000X (Licence: FL ME171952) | 
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: TX T3968) | 
| Enumeration Date | 2017-04-14 | 
| Last Update Date | 2025-04-25 |