| NPI | 1710354816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 13006) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 11648) |
| 2251S0007X Physical Therapist Sports | |
| 2251X0800X Physical Therapist Orthopedic | |
| Enumeration Date | 2015-08-25 |
| Last Update Date | 2016-08-18 |