| NPI | 1972767374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 8100) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 14129) |
| Enumeration Date | 2008-07-15 |
| Last Update Date | 2019-06-05 |