| NPI | 1083189856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ND 2493) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ND 879-20) |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2022-07-20 |