| NPI | 1710548201 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2084N0400X Psychiatry & Neurology, Neurology (Licence: KY TP497) | 
| Additional Taxonomies | 2084N0400X Psychiatry & Neurology, Neurology (Licence: MN 73389) | 
| 2084N0600X (Licence: KY TP497) | |
| Enumeration Date | 2019-06-25 | 
| Last Update Date | 2025-09-10 |