| NPI | 1962893487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 29997) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NJ 40QA01595500) |
| Enumeration Date | 2015-02-06 |
| Last Update Date | 2019-01-03 |