| NPI | 1003300963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60842213) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: AZ LPT30083) |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2025-10-13 |