| NPI | 1932643798 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305213235) | 
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1285153) | 
| Enumeration Date | 2016-12-14 | 
| Last Update Date | 2025-09-07 |