| NPI | 1164080438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 63253) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: OH PTO22121) |
| Enumeration Date | 2019-06-03 |
| Last Update Date | 2026-02-14 |