| NPI | 1295101558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA 024612) |
| Additional Taxonomies | 174400000X Specialist (Licence: WV 003530) |
| Enumeration Date | 2015-08-20 |
| Last Update Date | 2023-05-16 |