| NPI | 1013621911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT030851) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT004547) |
| Enumeration Date | 2023-01-06 |
| Last Update Date | 2023-01-06 |