| NPI | 1104610526 | 
|---|---|
| Entity Type | Individual | 
| Gender | N/A | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 13930) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 5227) | 
| Enumeration Date | 2025-04-09 | 
| Last Update Date | 2025-06-09 |