| NPI | 1063752160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OK 6101) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MO 2012037670) |
| 225200000X Physical Therapy Assistant (Licence: OK 6101) | |
| Enumeration Date | 2013-02-26 |
| Last Update Date | 2022-03-01 |