| NPI | 1912454992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: CO 0016994) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1278638) |
| Enumeration Date | 2016-09-07 |
| Last Update Date | 2021-02-02 |