| NPI | 1174144091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60151770) |
| Additional Taxonomies | 261QP2000X Clinic/Center Physical Therapy |
| Enumeration Date | 2020-05-01 |
| Last Update Date | 2023-01-30 |