| NPI | 1730231457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL0012619) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305203747) |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2026-04-29 |