| NPI | 1639691819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 62324) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305211080) |
| Enumeration Date | 2017-07-10 |
| Last Update Date | 2026-01-21 |