| NPI | 1053319194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: OK PT1084) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: OK AT19) |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2011-12-19 |