| NPI | 1225901309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 61701) |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2025-09-25 |
| Last Update Date | 2025-09-25 |