| NPI | 1962853051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL0016547) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 13482-24) |
| Enumeration Date | 2016-06-29 |
| Last Update Date | 2019-08-28 |