| NPI | 1053841742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12158) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 13888-24) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2021-06-30 |