| NPI | 1023155520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 11424-24) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 868039) |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2014-08-27 |