| NPI | 1609334572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: MA 293203) |
| Additional Taxonomies | 261QS1000X Clinic/Center, Student Health |
| Enumeration Date | 2019-03-08 |
| Last Update Date | 2022-10-26 |