| NPI | 1689140071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501018898) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0016671) |
| Enumeration Date | 2018-10-23 |
| Last Update Date | 2021-10-11 |