| NPI | 1255777892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC CPO15815T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305207955) |
| Enumeration Date | 2013-05-21 |
| Last Update Date | 2025-01-20 |