| NPI | 1639693872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305211339) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: VA 2305211339) |
| Enumeration Date | 2017-07-31 |
| Last Update Date | 2025-12-23 |