| NPI | 1154736676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR OR 60932) |
| Additional Taxonomies | 2251X0800X Physical Therapist Orthopedic (Licence: CO PTL.0012686) |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2015-07-16 |