| NPI | 1962058040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA CP010526T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1315625) |
| Enumeration Date | 2019-08-14 |
| Last Update Date | 2022-08-15 |