| NPI | 1215323845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT024196) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA DAPT003925) |
| Enumeration Date | 2015-04-10 |
| Last Update Date | 2022-09-28 |