| NPI | 1265011845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501019645) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 15329-24) |
| Enumeration Date | 2021-04-02 |
| Last Update Date | 2021-04-02 |