| NPI | 1851789572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT024700) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1251338) |
| 225100000X Physical Therapist (Licence: NC 15075) | |
| Enumeration Date | 2015-01-05 |
| Last Update Date | 2020-07-13 |