| NPI | 1295704336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305205009) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX 1163120) |
| 171000000X Military Health Care Provider (Licence: VA 2305205009) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2023-08-24 |