| NPI | 1962233379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 13639) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 17069-24) |
| Enumeration Date | 2024-08-08 |
| Last Update Date | 2025-09-25 |