| NPI | 1518481605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P21372) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: SC 7540) |
| Enumeration Date | 2017-07-31 |
| Last Update Date | 2022-08-08 |