| NPI | 1912280892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MS 5011) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2251S0007X Physical Therapist Sports (Licence: MS 5011) | |
| Enumeration Date | 2011-09-27 |
| Last Update Date | 2025-06-30 |