| NPI | 1912569013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA CP008663T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NH CP000171T) |
| 225100000X Physical Therapist (Licence: TN 12092) | |
| Enumeration Date | 2019-06-28 |
| Last Update Date | 2023-01-16 |