| NPI | 1306877592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225000000X Orthotic Fitter (Licence: WA PT00008235) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: WA PT00008235) |
| 2251X0800X Physical Therapist, Orthopedic (Licence: WA PT00008235) | |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2016-05-23 |