| NPI | 1023625019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305213977) |
| Enumeration Date | 2020-09-24 |
| Last Update Date | 2022-03-18 |