| NPI | 1568653707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 5363) |
| Additional Taxonomies | 2251P0200X Physical Therapist, Pediatrics (Licence: AZ 5363) |
| 2251S0007X Physical Therapist, Sports (Licence: AZ 5363) | |
| Enumeration Date | 2007-08-05 |
| Last Update Date | 2012-04-24 |