| NPI | 1942711882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 04311) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ID PT-2195) |
| Enumeration Date | 2017-10-18 |
| Last Update Date | 2017-10-18 |