| NPI | 1053924100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 43769) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: FL AL4834) |
| Enumeration Date | 2020-08-28 |
| Last Update Date | 2025-11-07 |