| NPI | 1619260528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501008050) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: MI 5501008050) |
| Enumeration Date | 2011-05-25 |
| Last Update Date | 2021-05-19 |