| NPI | 1174821250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: UT 106319-2401) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WY PT-0258) |
| Enumeration Date | 2011-03-14 |
| Last Update Date | 2011-03-14 |