| NPI | 1700485703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0018541) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 25117) |
| Enumeration Date | 2020-10-21 |
| Last Update Date | 2022-09-12 |