| NPI | 1861957227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: TX AT8650) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2019-02-08 |
| Last Update Date | 2022-05-08 |