| NPI | 1508426164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305212908) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: VA 2305212908) |
| Enumeration Date | 2019-06-17 |
| Last Update Date | 2020-09-17 |