| NPI | 1073508677 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305214847) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT010119L) |
| 2251S0007X Physical Therapist, Sports (Licence: PA PT010119L) | |
| 2251X0800X Physical Therapist, Orthopedic (Licence: PA PT010119L) | |
| Enumeration Date | 2005-09-20 |
| Last Update Date | 2022-02-11 |