| NPI | 1205320405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM PT5353) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305212070) |
| Enumeration Date | 2018-06-20 |
| Last Update Date | 2018-09-12 |