| NPI | 1912766916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT61231005) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: VA 2305211938) |
| Enumeration Date | 2024-03-13 |
| Last Update Date | 2024-11-14 |