| NPI | 1639821754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 16645-24) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ LPT-31795) |
| Enumeration Date | 2022-01-20 |
| Last Update Date | 2026-04-28 |