| NPI | 1427567536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12120) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 23606) |
| 225100000X Physical Therapist (Licence: CA 294274) | |
| 225100000X Physical Therapist (Licence: OR 62304) | |
| Enumeration Date | 2017-09-21 |
| Last Update Date | 2021-05-24 |