| NPI | 1154964278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NE 4137) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: MN 11561) |
| Enumeration Date | 2019-10-21 |
| Last Update Date | 2020-10-12 |