| NPI | 1104439157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AK CP058771T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MT PRD-PT-LIC-31705) |
| Enumeration Date | 2020-08-28 |
| Last Update Date | 2026-06-22 |