| NPI | 1104491042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2021024159) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 225100000X Physical Therapist (Licence: KS 11-06716) | |
| Enumeration Date | 2021-05-24 |
| Last Update Date | 2021-07-30 |