| NPI | 1407553241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 11680) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 225100000X Physical Therapist (Licence: NM PT-2023-2365) | |
| Enumeration Date | 2023-02-13 |
| Last Update Date | 2023-12-12 |