| NPI | 1619563640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1359290) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: OR 63722) |
| Enumeration Date | 2020-12-14 |
| Last Update Date | 2023-12-07 |