| NPI | 1124358890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 8619) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 00502) |
| Enumeration Date | 2010-01-01 |
| Last Update Date | 2010-01-01 |