| NPI | 1124475074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P19546) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 10373) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2016-05-20 |
| Last Update Date | 2026-06-30 |