| NPI | 1619639150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SD CP002171) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: SD CP002171) |
| Enumeration Date | 2021-10-12 |
| Last Update Date | 2021-10-18 |