| NPI | 1659264810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 132299) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT-2025-0138) |
| Enumeration Date | 2025-05-29 |
| Last Update Date | 2025-06-03 |