| NPI | 1376328559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM PT-2025-0355) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305216018) |
| Enumeration Date | 2023-08-28 |
| Last Update Date | 2026-06-12 |