| NPI | 1821695743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1378852) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: FL PT36218) |
| Enumeration Date | 2020-10-04 |
| Last Update Date | 2024-07-02 |