| NPI | 1104640085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OH PT021558) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH 2000052565) |
| Enumeration Date | 2024-11-08 |
| Last Update Date | 2025-02-25 |