| NPI | 1710290713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: PA OT013853) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: CA 20A12785) |
| Enumeration Date | 2010-07-19 |
| Last Update Date | 2021-12-02 |