| NPI | 1720605736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305216871) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 044464) |
| Enumeration Date | 2020-06-25 |
| Last Update Date | 2025-08-21 |