| NPI | 1962141754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD 29557) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA PT030377) |
| Enumeration Date | 2022-06-01 |
| Last Update Date | 2023-07-27 |