| NPI | 1063761138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 20161) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 1658) |
| Enumeration Date | 2012-09-05 |
| Last Update Date | 2012-09-05 |