| NPI | 1679271068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 33301) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 16146) |
| Enumeration Date | 2023-02-16 |
| Last Update Date | 2024-08-30 |