| NPI | 1104486976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AR PT4629) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2025-05-08 |