| NPI | 1114901147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT00002911) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OR 1017) |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2007-07-08 |