| NPI | 1053712166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NV 3099) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1207843) |
| 2251S0007X Physical Therapist Sports (Licence: NV 3099) | |
| 2251X0800X Physical Therapist Orthopedic (Licence: NV 3099) | |
| Enumeration Date | 2014-09-08 |
| Last Update Date | 2022-08-16 |