| NPI | 1053984542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 64058) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: OR 64058) |
| Enumeration Date | 2021-07-21 |
| Last Update Date | 2021-07-21 |