| NPI | 1255980488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: LA 11040) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: LA A9207) |
| Enumeration Date | 2019-09-10 |
| Last Update Date | 2022-08-03 |