| NPI | 1609334572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NM RS2025-0145) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: NM RS2025-0145) |
| 261QS1000X Clinic/Center, Student Health | |
| Enumeration Date | 2019-03-08 |
| Last Update Date | 2025-07-01 |