| NPI | 1255054102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ID 9171049) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 12628) |
| Enumeration Date | 2022-09-26 |
| Last Update Date | 2025-09-27 |