| NPI | 1568712651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2012030850) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-04466) |
| Enumeration Date | 2012-09-15 |
| Last Update Date | 2012-09-20 |