| NPI | 1255945473 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AR PT4884) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: TX 1338031) |
| Enumeration Date | 2020-09-04 |
| Last Update Date | 2021-04-15 |