| NPI | 1679258800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 050033) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: NY 013254) |
| Enumeration Date | 2023-06-15 |
| Last Update Date | 2023-06-15 |