| NPI | 1669835518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2081P2900X Physical Medicine & Rehabilitation, Pain Medicine (Licence: NE 33039) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0116029933) |
| Enumeration Date | 2016-03-29 |
| Last Update Date | 2026-07-21 |