| NPI | 1023615309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM PT-2025-0113) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO 16960) |
| Enumeration Date | 2020-10-08 |
| Last Update Date | 2025-06-17 |