| NPI | 1982281911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208VP0000X (Licence: TX W8819) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: WA OP61427421) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-25 |
| Last Update Date | 2026-10-01 |