| NPI | 1083736771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305002380) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO R0345) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126000443) | |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2007-07-08 |