| NPI | 1639205719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MT 2351PT) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MT 2351pt) |
| 225100000X Physical Therapist (Licence: MN 7805) | |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2018-05-07 |