| NPI | 1235648312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WY 1748) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 225100000X Physical Therapist (Licence: TX 1292939) | |
| Enumeration Date | 2017-09-21 |
| Last Update Date | 2019-08-30 |