| NPI | 1033674890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT031095) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 261QP2000X Clinic/Center, Physical Therapy (Licence: PA PT031095) | |
| Enumeration Date | 2019-02-06 |
| Last Update Date | 2023-05-16 |