| NPI | 1114117280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT023403) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: PA PT023403) |
| Enumeration Date | 2007-07-25 |
| Last Update Date | 2017-05-10 |