| NPI | 1225493612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1300729) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 25799) |
| 225100000X Physical Therapist (Licence: NM 4514) | |
| Enumeration Date | 2015-12-29 |
| Last Update Date | 2020-01-03 |