| NPI | 1003469461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: MI 5501017348) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001039) |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2019-07-24 |