| NPI | 1811203706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: WI 66097-20) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 11468) |
| Enumeration Date | 2010-08-30 |
| Last Update Date | 2019-09-20 |