| NPI | 1114582954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4723) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: SC 9682) |
| Enumeration Date | 2019-05-07 |
| Last Update Date | 2023-03-08 |