| NPI | 1396263885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1298447) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2017-09-05 |
| Last Update Date | 2026-02-05 |