| NPI | 1578175113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: AZ 32650) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OR P19756) |
| Enumeration Date | 2020-08-17 |
| Last Update Date | 2026-04-13 |