| NPI | 1639494073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2019013315) |
| Additional Taxonomies | 226300000X Kinesiotherapist (Licence: KS YA-34381) |
| 225700000X Massage Therapist (Licence: KS 09980-01073) | |
| Enumeration Date | 2010-03-29 |
| Last Update Date | 2026-02-20 |