| NPI | 1891209987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NM 5157) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: CT 11240) |
| Enumeration Date | 2017-11-28 |
| Last Update Date | 2019-05-24 |