| NPI | 1912675505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA CP017657T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305214671) |
| Enumeration Date | 2021-08-31 |
| Last Update Date | 2023-01-18 |