| NPI | 1104250539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT022955) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305208250) |
| Enumeration Date | 2013-08-21 |
| Last Update Date | 2018-05-24 |