| NPI | 1538723564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: LA 12343R) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: MS PT4504) |
| 2251S0007X Physical Therapist, Sports (Licence: MS PT4504) | |
| Enumeration Date | 2019-04-25 |
| Last Update Date | 2026-05-21 |