| NPI | 1962493759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 4658-024) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CO 5320) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2007-07-08 |