| NPI | 1790128809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: NC 2018-01194) |
| Additional Taxonomies | 207QS0010X Family Medicine, Sports Medicine (Licence: NC 2018-01194) |
| 208100000X Physical Medicine & Rehabilitation (Licence: NC 2018-01194) | |
| Enumeration Date | 2013-04-09 |
| Last Update Date | 2021-06-03 |