| NPI | 1174929814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305206952) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 12590-24) |
| Enumeration Date | 2014-11-07 |
| Last Update Date | 2024-05-07 |