| NPI | 1679912877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 76582) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: MT 174135) |
| Enumeration Date | 2013-06-20 |
| Last Update Date | 2026-08-03 |