| NPI | 1154713501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P15435) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0013649) |
| 225100000X Physical Therapist (Licence: MT PTP-PT-LIC-9394) | |
| 225100000X Physical Therapist (Licence: AZ LIC-30420) | |
| Enumeration Date | 2015-02-23 |
| Last Update Date | 2019-02-20 |