| NPI | 1679212021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: LA 11203) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: LA 11203) |
| 2251X0800X Physical Therapist Orthopedic (Licence: LA 11203) | |
| Enumeration Date | 2022-06-02 |
| Last Update Date | 2022-06-02 |