| NPI | 1205591955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD 28544) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OR 64114) |
| Enumeration Date | 2021-11-07 |
| Last Update Date | 2025-09-11 |