| NPI | 1902419237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0017641) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MI 5501019712) |
| Enumeration Date | 2020-08-26 |
| Last Update Date | 2026-06-04 |