| NPI | 1790211407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305210789) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC 16743) |
| 225100000X Physical Therapist (Licence: SC 8857) | |
| 225100000X Physical Therapist (Licence: AK 120724) | |
| Enumeration Date | 2017-05-02 |
| Last Update Date | 2018-02-05 |