| NPI | 1306405048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305212759) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: VA 2305212759) |
| Enumeration Date | 2019-06-06 |
| Last Update Date | 2022-01-13 |