| NPI | 1710434154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 64290) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: TX 2123907) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2022-01-13 |