| NPI | 1194394528 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0020536) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 2021033700) | 
| 225100000X Physical Therapist (Licence: TN 16293) | |
| Enumeration Date | 2021-06-21 | 
| Last Update Date | 2025-05-26 |