| NPI | 1205482106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: MA 26027) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 27635) |
| Enumeration Date | 2019-08-15 |
| Last Update Date | 2022-03-17 |