| NPI | 1790119436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO 0012253) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WY PT-1625) |
| Enumeration Date | 2013-08-29 |
| Last Update Date | 2020-03-18 |