| NPI | 1205392537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1324772) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: VA 2305212496) |
| Enumeration Date | 2019-02-12 |
| Last Update Date | 2019-09-23 |