| NPI | 1104855683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 117614) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-01870) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2022-05-02 |