| NPI | 1790264448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2020007692) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WA PT60878362) |
| Enumeration Date | 2018-08-13 |
| Last Update Date | 2020-03-03 |