| NPI | 1790046084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC 12798) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC P12798) |
| 225100000X Physical Therapist (Licence: MI 5501015180) | |
| Enumeration Date | 2012-06-03 |
| Last Update Date | 2013-04-26 |