| NPI | 1174138408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 38617) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 25196) |
| Enumeration Date | 2020-09-14 |
| Last Update Date | 2022-06-21 |