| NPI | 1245837889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12109) |
| Additional Taxonomies | 2251X0800X Physical Therapist Orthopedic (Licence: TX 1309532) |
| Enumeration Date | 2020-10-06 |
| Last Update Date | 2020-12-15 |