| NPI | 1063768596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT010697) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001686) |
| Enumeration Date | 2012-08-02 |
| Last Update Date | 2017-04-18 |