| NPI | 1942676176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SC 8572) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT 003526) |
| Enumeration Date | 2015-08-11 |
| Last Update Date | 2022-07-21 |