| NPI | 1174189864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 15755-24) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WA PT60964671) |
| 225100000X Physical Therapist (Licence: CO PTL.0017664) | |
| Enumeration Date | 2019-05-17 |
| Last Update Date | 2023-06-21 |