| NPI | 1104903426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305005665) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT001777) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2023-11-28 |