| NPI | 1093228470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT43430) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL6056) |
| Enumeration Date | 2017-11-08 |
| Last Update Date | 2025-09-03 |