| NPI | 1619706579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA CP048641T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IA 126888) |
| 225100000X Physical Therapist (Licence: MO CP033140T) | |
| Enumeration Date | 2024-07-30 |
| Last Update Date | 2025-08-14 |