| NPI | 1902230873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 18370) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NJ 40QA01515000) |
| Enumeration Date | 2013-08-28 |
| Last Update Date | 2019-06-18 |