| NPI | 1104702711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2025050001) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IL 070.029269) |
| Enumeration Date | 2025-08-12 |
| Last Update Date | 2026-01-13 |