| NPI | 1104201383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 11346) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 2012004484) |
| Enumeration Date | 2015-07-29 |
| Last Update Date | 2020-10-13 |