| NPI | 1992006662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171W00000X Contractor (Licence: UT 49112992401) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: UT 4911299-2401) |
| Enumeration Date | 2010-11-10 |
| Last Update Date | 2021-07-05 |