| NPI | 1194459552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12781) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: ME PT6228) |
| Enumeration Date | 2022-07-12 |
| Last Update Date | 2026-06-01 |