| NPI | 1083665475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 8422) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 734) |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2014-05-27 |