| NPI | 1790469005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NJ 40QA02175500) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT034361) |
| Enumeration Date | 2023-06-15 |
| Last Update Date | 2026-08-26 |