| NPI | 1154802890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: OR 06173) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT033127) |
| Enumeration Date | 2018-08-21 |
| Last Update Date | 2026-03-25 |