| NPI | 1356612147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT001619E) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT22787) |
| Enumeration Date | 2012-01-25 |
| Last Update Date | 2018-03-06 |