| NPI | 1164805123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WY PT-1776) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ID PT-4243) |
| 225100000X Physical Therapist (Licence: NE 3392) | |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2018-04-24 |