| NPI | 1306498613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 15290) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 11604) |
| Enumeration Date | 2019-07-16 |
| Last Update Date | 2022-11-01 |