| NPI | 1134150816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MS PT2160) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MS AT0161) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2012-08-03 |