| NPI | 1003658618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: SD 6069) |
| Enumeration Date | 2024-06-12 |
| Last Update Date | 2025-10-24 |