| NPI | 1366033748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ LPT-31494) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 11810) |
| Enumeration Date | 2021-01-28 |
| Last Update Date | 2021-01-28 |