| NPI | 1053799122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 4032) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1251628) |
| Enumeration Date | 2015-05-11 |
| Last Update Date | 2015-05-11 |