| NPI | 1124485453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P15485) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305209282) |
| Enumeration Date | 2016-01-17 |
| Last Update Date | 2016-01-17 |