| NPI | 1063765493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT 60076540) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CA PT 33536) |
| Enumeration Date | 2012-10-23 |
| Last Update Date | 2013-03-15 |