| NPI | 1639907850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 12815) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT-2024-0333) |
| Enumeration Date | 2024-07-22 |
| Last Update Date | 2025-04-22 |