| NPI | 1245746601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0017304) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT33262) |
| Enumeration Date | 2017-12-21 |
| Last Update Date | 2021-03-10 |