| NPI | 1023091584 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1026052) | 
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: TX 1026052) | 
| Enumeration Date | 2005-11-29 | 
| Last Update Date | 2023-12-15 |