| NPI | 1104879345 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: AZ 5009) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 5009) | 
| 2251S0007X Physical Therapist, Sports (Licence: AZ 5009) | |
| Enumeration Date | 2006-05-18 | 
| Last Update Date | 2025-09-11 |