| NPI | 1518363753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305210723) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VT 0400104671) |
| Enumeration Date | 2014-11-17 |
| Last Update Date | 2023-08-24 |