| NPI | 1629858816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 13291) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 16557) |
| Enumeration Date | 2023-10-04 |
| Last Update Date | 2026-04-09 |