| NPI | 1942807896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: UT 13666417-2401) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 25089) |
| Enumeration Date | 2020-10-05 |
| Last Update Date | 2026-06-29 |