| NPI | 1770791972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KS 1104036) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 109150) |
| 2251S0007X Physical Therapist, Sports (Licence: KS 1104036) | |
| Enumeration Date | 2007-05-19 |
| Last Update Date | 2011-12-30 |