| NPI | 1083063564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P22102) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1274737) |
| 2251S0007X Physical Therapist, Sports (Licence: TX 1274737) | |
| 2251S0007X Physical Therapist, Sports (Licence: NC P22102) | |
| Enumeration Date | 2016-06-06 |
| Last Update Date | 2025-07-21 |