| NPI | 1053035261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 16111) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 13206) |
| Enumeration Date | 2022-09-30 |
| Last Update Date | 2023-08-01 |