| NPI | 1104164953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1209776) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0012098) |
| Enumeration Date | 2013-01-28 |
| Last Update Date | 2020-04-16 |