| NPI | 1649252164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT00005681) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: WA PT00005681) |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2020-09-01 |