| NPI | 1184339699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P21873) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: NC P21873) |
| Enumeration Date | 2023-01-18 |
| Last Update Date | 2026-08-19 |