| NPI | 1912424037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 10706) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 24552) |
| Enumeration Date | 2017-08-29 |
| Last Update Date | 2022-04-18 |