| NPI | 1730776147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 13436) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO 17422) |
| Enumeration Date | 2020-12-31 |
| Last Update Date | 2026-02-18 |