| NPI | 1104902998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251E1300X Physical Therapist, Electrophysiology, Clinical (Licence: GA PT000495) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: GA PT000495) |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2011-02-28 |