| NPI | 1104895200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305210224) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT017332) |
| 225100000X Physical Therapist (Licence: NE 2744) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2022-04-12 |