| NPI | 1114041381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 2491) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OR AT-AT-183301) |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2007-07-08 |