| NPI | 1619696796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: LA 12281R) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TN 14177) |
| Enumeration Date | 2022-08-23 |
| Last Update Date | 2026-05-13 |