| NPI | 1154164309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KY 009165) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MO 2023032337) |
| Enumeration Date | 2024-06-17 |
| Last Update Date | 2024-08-14 |