| NPI | 1134775588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 25344) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AL PTH9524) |
| Enumeration Date | 2019-08-12 |
| Last Update Date | 2021-01-21 |