| NPI | 1639680267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MN 35422) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT026400) |
| Enumeration Date | 2017-10-23 |
| Last Update Date | 2025-08-25 |