| NPI | 1063629301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ND 386) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 5799) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ND 021-84) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1306) | |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2007-07-08 |