| NPI | 1578212973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT030531) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-03-22 |
| Last Update Date | 2024-02-28 |