| NPI | 1407101520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60977962) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IA 004986) |
| 225100000X Physical Therapist (Licence: NE 3100) | |
| Enumeration Date | 2012-07-15 |
| Last Update Date | 2019-07-16 |