| NPI | 1609120336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT023173) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 6755) |
| 225100000X Physical Therapist (Licence: FL 27839) | |
| Enumeration Date | 2012-11-02 |
| Last Update Date | 2014-03-10 |