| NPI | 1760962856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 225100000X Physical Therapist |
| Enumeration Date | 2018-08-17 |
| Last Update Date | 2025-05-18 |