| NPI | 1912996968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 6672) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MT 1876) |
| 225100000X Physical Therapist (Licence: WA PT60210474) | |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2012-02-17 |