| NPI | 1063087013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 2817) |
| Enumeration Date | 2021-05-21 |
| Last Update Date | 2026-08-20 |