| NPI | 1225625759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 105500) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WY PT-1979) |
| Enumeration Date | 2020-12-30 |
| Last Update Date | 2020-12-30 |