| NPI | 1215323605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305208921) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT023059) |
| 225100000X Physical Therapist (Licence: SC 7363) | |
| Enumeration Date | 2015-04-13 |
| Last Update Date | 2015-04-13 |