| NPI | 1558955039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT029111) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-06668) |
| Enumeration Date | 2021-02-24 |
| Last Update Date | 2022-11-08 |