| NPI | 1366964256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KY 9269) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 30338) |
| Enumeration Date | 2017-07-12 |
| Last Update Date | 2025-08-13 |