| NPI | 1922645167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305213346) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CT 12490) |
| Enumeration Date | 2019-12-06 |
| Last Update Date | 2019-12-11 |