| NPI | 1265150635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 64660) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0018593) |
| Enumeration Date | 2022-08-22 |
| Last Update Date | 2023-02-01 |