| NPI | 1629688700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1407376) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: TX 2156230) |
| Enumeration Date | 2020-08-04 |
| Last Update Date | 2025-09-02 |