| NPI | 1124258678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1199645) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NE 2774) |
| 225100000X Physical Therapist (Licence: PA PT019992) | |
| Enumeration Date | 2009-07-17 |
| Last Update Date | 2025-11-04 |