| NPI | 1093231714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 11294) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-626) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL3967) | |
| 2251S0007X Physical Therapist, Sports (Licence: ID PT-5264) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1947) | |
| Enumeration Date | 2017-08-15 |
| Last Update Date | 2018-09-27 |