| NPI | 1104805894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: DE J1-0002057) |
| Additional Taxonomies | 174400000X Specialist (Licence: PA PT017504) |
| Enumeration Date | 2006-01-11 |
| Last Update Date | 2011-01-13 |