| NPI | 1972027001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0016896) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1309412) |
| Enumeration Date | 2017-07-31 |
| Last Update Date | 2020-12-22 |