| NPI | 1376258855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501302145) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OR 65785) |
| Enumeration Date | 2023-01-18 |
| Last Update Date | 2025-09-08 |