| NPI | 1790965408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2007024553) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 7895) |
| 225100000X Physical Therapist (Licence: KS 1103756) | |
| Enumeration Date | 2007-11-09 |
| Last Update Date | 2007-11-09 |