| NPI | 1972944122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AL PTH7643) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CO PTL.0011451) |
| Enumeration Date | 2013-07-16 |
| Last Update Date | 2015-09-29 |