| NPI | 1104273994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: VA 2305212758) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2016-05-21 |
| Last Update Date | 2019-05-22 |