| NPI | 1104219914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT002638) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305202488) |
| Enumeration Date | 2015-03-18 |
| Last Update Date | 2021-01-19 |