| NPI | 1255717542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P18954) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-05217) |
| Enumeration Date | 2015-08-10 |
| Last Update Date | 2021-08-03 |