| NPI | 1316668171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 65243) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT030770) |
| Enumeration Date | 2022-09-08 |
| Last Update Date | 2024-12-23 |