| NPI | 1700554458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 64229) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic |
| Enumeration Date | 2021-08-30 |
| Last Update Date | 2025-06-02 |