| NPI | 1538766720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251C2600X (Licence: WI 1572324) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: UT 11285279-2401) |
| Enumeration Date | 2020-10-01 |
| Last Update Date | 2025-07-23 |