| NPI | 1972794360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 12211) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 7920) |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2021-04-13 |