| NPI | 1962112961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: VA 2305206922) |
| Additional Taxonomies | 225100000X Physical Therapist |
| Enumeration Date | 2022-11-30 |
| Last Update Date | 2023-04-18 |