| NPI | 1780056622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT018133) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: GA pta003294) |
| Enumeration Date | 2015-10-29 |
| Last Update Date | 2025-12-16 |