| NPI | 1619647062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 15624) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 12235) |
| Enumeration Date | 2021-09-16 |
| Last Update Date | 2024-06-28 |