| NPI | 1083014617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KS T-05045) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: KS 14-01776) |
| Enumeration Date | 2014-09-02 |
| Last Update Date | 2021-10-26 |