| NPI | 1659139350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: TX BP10097412) |
| Additional Taxonomies | 261QP2000X Clinic/Center, Physical Therapy (Licence: NY 042399-01) |
| Enumeration Date | 2024-03-08 |
| Last Update Date | 2026-05-08 |