| NPI | 1700585320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1372835) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT-2023-2038) |
| Enumeration Date | 2023-03-02 |
| Last Update Date | 2024-02-07 |