| NPI | 1922613033 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 055136) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 2020025036) | 
| Enumeration Date | 2020-09-15 | 
| Last Update Date | 2025-10-09 |