| NPI | 1154569192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P11859) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NC 11859) |
| Enumeration Date | 2009-01-29 |
| Last Update Date | 2023-08-14 |