| NPI | 1154727873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND 735) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ND 1565) |
| Enumeration Date | 2014-11-06 |
| Last Update Date | 2021-12-20 |