| NPI | 1902367352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: FL ME159166) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: WA MD.MD.61425224) |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2026-04-30 |