| NPI | 1215713524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 12305) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 050775) |
| Enumeration Date | 2023-09-01 |
| Last Update Date | 2024-11-13 |