| NPI | 1912548629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305213180) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 28089) |
| Enumeration Date | 2019-10-03 |
| Last Update Date | 2023-07-31 |