| NPI | 1194316455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: WI 14657-24) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: WI 14657-24) |
| Enumeration Date | 2021-01-29 |
| Last Update Date | 2021-01-29 |