| NPI | 1104874544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT008548L) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT002030A) |
| Enumeration Date | 2006-05-05 |
| Last Update Date | 2016-11-02 |