| NPI | 1104301050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305211909) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WY 1832) |
| Enumeration Date | 2018-09-26 |
| Last Update Date | 2018-10-02 |