| NPI | 1740012111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 14255) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 13664) |
| 225100000X Physical Therapist (Licence: SC 12183) | |
| 225100000X Physical Therapist (Licence: CO 19784) | |
| Enumeration Date | 2024-08-15 |
| Last Update Date | 2025-03-31 |