| NPI | 1619111564 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: CA A123020)  | 
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: NY 000)  | 
| Enumeration Date | 2009-04-22 | 
| Last Update Date | 2025-01-22 |