| NPI | 1366040594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WY PT2029) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0017406) |
| Enumeration Date | 2020-10-09 |
| Last Update Date | 2021-12-01 |