| NPI | 1174009120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 14816) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 11211) |
| Enumeration Date | 2018-07-12 |
| Last Update Date | 2020-03-30 |