| NPI | 1700329430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: CT 001121) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: CT 018070) |
| Enumeration Date | 2016-11-29 |
| Last Update Date | 2021-10-28 |