| NPI | 1649058140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P24098) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: KS 11-07454) |
| Enumeration Date | 2023-09-18 |
| Last Update Date | 2025-08-18 |