| NPI | 1760802508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084N0400X Psychiatry & Neurology, Neurology (Licence: MN 63736) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2014-04-20 |
| Last Update Date | 2018-05-15 |