| NPI | 1104288224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 12328) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 1463) |
| Enumeration Date | 2016-03-28 |
| Last Update Date | 2016-06-29 |