| NPI | 1710565098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA MT236578) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT028639) |
| Enumeration Date | 2021-03-30 |
| Last Update Date | 2026-05-14 |