| NPI | 1134499569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60745535) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A1 60256210) |
| Enumeration Date | 2012-01-02 |
| Last Update Date | 2022-07-21 |