| NPI | 1174653828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: NM 2248) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0012624) |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2017-11-21 |