| NPI | 1720342470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: FL 32599) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA9106514) |
| Enumeration Date | 2012-06-27 |
| Last Update Date | 2021-05-05 |