| NPI | 1063078004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2019020965) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-06186) |
| Enumeration Date | 2019-05-15 |
| Last Update Date | 2019-06-17 |