| NPI | 1104484583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 12274) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 043794) |
| Enumeration Date | 2019-05-31 |
| Last Update Date | 2026-07-13 |