| NPI | 1720395114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 320700000X Residential Treatment Facility, Physical Disabilities (Licence: MN 62743) |
| Additional Taxonomies | 207L00000X Anesthesiology (Licence: NY 276058) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-09-07 |
| Last Update Date | 2023-01-06 |