| NPI | 1255060604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 42629) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: FL 42629) |
| 2251X0800X Physical Therapist, Orthopedic (Licence: FL 42629) | |
| Enumeration Date | 2022-06-09 |
| Last Update Date | 2025-08-08 |