| NPI | 1104307610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD 25740) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA PTL25782) |
| Enumeration Date | 2018-08-22 |
| Last Update Date | 2023-08-08 |