| NPI | 1053862342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NE 4243) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NE 865) |
| Enumeration Date | 2016-10-20 |
| Last Update Date | 2021-07-05 |