| NPI | 1376149146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12013) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 15292) |
| Enumeration Date | 2020-12-08 |
| Last Update Date | 2022-01-18 |