| NPI | 1902259401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 095960) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO PTL.0013959) |
| 225100000X Physical Therapist (Licence: MO 2016020602) | |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2019-09-13 |