| NPI | 1053915819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT36549) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OR 66114) |
| Enumeration Date | 2020-11-23 |
| Last Update Date | 2026-06-19 |