| NPI | 1790392058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD 28140) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT004346) |
| Enumeration Date | 2020-09-30 |
| Last Update Date | 2025-05-07 |