| NPI | 1649861071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: UT 11797529-2401) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: UT 11797529-4701) |
| Enumeration Date | 2021-01-28 |
| Last Update Date | 2025-12-02 |