| NPI | 1740931641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA CP053748) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: LA 10932) |
| Enumeration Date | 2022-01-12 |
| Last Update Date | 2026-08-27 |