| NPI | 1205309739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT016382) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0016166) |
| Enumeration Date | 2019-01-08 |
| Last Update Date | 2022-12-19 |