| NPI | 1063129450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT031978) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: VA 2305215477) |
| Enumeration Date | 2022-11-03 |
| Last Update Date | 2024-01-24 |