| NPI | 1790782647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT001192E) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: PA PT 001192e) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2017-02-20 |