| NPI | 1689114340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM PT-2024-0123) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC 16852) |
| Enumeration Date | 2017-02-28 |
| Last Update Date | 2026-08-11 |