| NPI | 1013284827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA R-12999) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: NE 1076) |
| 225200000X Physical Therapy Assistant (Licence: OH PTA 06459) | |
| Enumeration Date | 2011-11-22 |
| Last Update Date | 2023-08-09 |