| NPI | 1023146701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VT 040-0002739) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VT 104-0000015) |
| Enumeration Date | 2007-03-02 |
| Last Update Date | 2007-08-22 |