| NPI | 1740731843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT028652) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: PA TEI003633) |
| Enumeration Date | 2016-10-24 |
| Last Update Date | 2020-10-13 |