| NPI | 1104320423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60821839) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: SC 9026) |
| Enumeration Date | 2018-03-21 |
| Last Update Date | 2019-09-26 |