| NPI | 1174036966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 12271) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT1532) |
| Enumeration Date | 2017-11-15 |
| Last Update Date | 2021-05-14 |