| NPI | 1619329703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM 5279) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0014097) |
| Enumeration Date | 2016-07-12 |
| Last Update Date | 2022-04-07 |