| NPI | 1063991164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 12454) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305212243) |
| 225100000X Physical Therapist (Licence: VT 040.0134031) | |
| Enumeration Date | 2018-08-09 |
| Last Update Date | 2021-03-11 |