| NPI | 1376919142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1263727) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 12004) |
| Enumeration Date | 2015-08-17 |
| Last Update Date | 2023-07-20 |