| NPI | 1164079927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: PA PT019676) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 25259) |
| Enumeration Date | 2019-08-26 |
| Last Update Date | 2020-11-20 |