| NPI | 1760021760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA CP007480T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT004357) |
| Enumeration Date | 2019-12-23 |
| Last Update Date | 2021-07-23 |