| NPI | 1215544119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12048) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 15195-24) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2022-01-27 |