| NPI | 1356912802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 64509) |
| Additional Taxonomies | 2251X0800X Physical Therapist Orthopedic (Licence: MT PTP-PT-LIC-21667) |
| Enumeration Date | 2021-07-06 |
| Last Update Date | 2022-08-25 |