| NPI | 1679817993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC 14842) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305207696) |
| Enumeration Date | 2012-11-27 |
| Last Update Date | 2014-10-07 |