| NPI | 1790415818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2022031575) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-07045) |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2022-08-23 |