| NPI | 1619105806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 8516) |
| Additional Taxonomies | 2251P0200X Physical Therapist Pediatrics (Licence: AZ 8516) |
| Enumeration Date | 2009-06-25 |
| Last Update Date | 2009-06-25 |