| NPI | 1679013619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305210883) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: VA 2305210883) |
| 2251X0800X Physical Therapist Orthopedic (Licence: VA 2305210883) | |
| Enumeration Date | 2017-02-23 |
| Last Update Date | 2017-02-23 |