| NPI | 1306629001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WY PT-2318) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ME PT7069) |
| Enumeration Date | 2023-08-16 |
| Last Update Date | 2025-04-16 |