| NPI | 1629526611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 17365-24) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: WI 2478-19) |
| Enumeration Date | 2016-09-19 |
| Last Update Date | 2025-06-27 |