| NPI | 1255172235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251S0007X Physical Therapist Sports (Licence: MO 2023021800) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 2023021800) |
| Enumeration Date | 2024-06-04 |
| Last Update Date | 2024-06-04 |