| NPI | 1912350265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 14557-24) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 10358) |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2025-01-23 |