| NPI | 1154939171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 11910) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports |
| Enumeration Date | 2020-07-15 |
| Last Update Date | 2020-07-21 |