| NPI | 1114164423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 13222) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: FL PT 28462) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2009-01-09 |
| Last Update Date | 2025-08-27 |