| NPI | 1154632628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: CO 11712) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 6184) |
| Enumeration Date | 2010-06-29 |
| Last Update Date | 2021-12-10 |