| NPI | 1194265421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60045069) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 22749) |
| Enumeration Date | 2017-03-06 |
| Last Update Date | 2025-12-05 |