| NPI | 1619552874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12068) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 15180-24) |
| Enumeration Date | 2021-03-09 |
| Last Update Date | 2021-03-09 |