| NPI | 1265218812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD CP050932T) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: VA 2305216039) |
| Enumeration Date | 2023-09-07 |
| Last Update Date | 2025-12-05 |