| NPI | 1740792613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT013932) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 041965) |
| Enumeration Date | 2017-10-31 |
| Last Update Date | 2019-10-14 |