| NPI | 1124659354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA 61085889) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CA PT297898) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CA 2000016385) | |
| Enumeration Date | 2020-01-27 |
| Last Update Date | 2020-11-22 |