| NPI | 1104285774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P16997) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT025018) |
| Enumeration Date | 2016-02-11 |
| Last Update Date | 2017-04-18 |