| NPI | 1104906437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT007079) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 4215) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2012-02-23 |