| NPI | 1073704441 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 6442-024) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WI 361-039) |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2007-10-03 |