| NPI | 1700429859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2016029272) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-05450) |
| Enumeration Date | 2019-10-22 |
| Last Update Date | 2025-11-26 |