| NPI | 1225677768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225200000X Physical Therapy Assistant (Licence: TX 2123567) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: TX AT1201) |
| Enumeration Date | 2020-01-01 |
| Last Update Date | 2020-01-01 |