| NPI | 1982362968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 39536) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 11063) |
| Enumeration Date | 2021-12-07 |
| Last Update Date | 2022-12-07 |