| NPI | 1164023941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12352) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 15289-24) |
| Enumeration Date | 2020-11-06 |
| Last Update Date | 2021-09-23 |