| 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 |