| NPI | 1154005189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P22705) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: VA 2305245777) |
| Enumeration Date | 2023-06-12 |
| Last Update Date | 2025-10-22 |