| NPI | 1861851214 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: TX 1268578) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CA 292585) |
| Enumeration Date | 2016-02-14 |
| Last Update Date | 2026-02-16 |