| NPI | 1194390815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: OR 64109) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 12875) |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2022-10-28 |