| NPI | 1740064930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: UT 14236413-2401) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NM PT6146) |
| Enumeration Date | 2023-08-21 |
| Last Update Date | 2025-11-13 |