| NPI | 1770925257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1896) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ID PT-3184) |
| Enumeration Date | 2013-07-24 |
| Last Update Date | 2021-03-09 |