| NPI | 1972097913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P19916) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 043084) |
| Enumeration Date | 2018-06-21 |
| Last Update Date | 2025-10-13 |