| NPI | 1730754623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P22107) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305214289) |
| Enumeration Date | 2021-05-24 |
| Last Update Date | 2026-04-22 |