| NPI | 1134715485 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305215905) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 046802) | 
| 225100000X Physical Therapist (Licence: PA PT031252) | |
| Enumeration Date | 2020-12-21 | 
| Last Update Date | 2025-08-08 |