| NPI | 1104237726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VT 040-0103934) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VT 2000006432) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VT 104-0078895) | |
| Enumeration Date | 2014-05-16 |
| Last Update Date | 2020-06-10 |