| NPI | 1386639763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WY 1763) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 9632024) |
| 2251X0800X Physical Therapist, Orthopedic (Licence: WY PT-1763) | |
| Enumeration Date | 2005-09-13 |
| Last Update Date | 2023-07-03 |