| NPI | 1134540800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305208475) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ME 4123) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2169) | |
| Enumeration Date | 2013-12-26 |
| Last Update Date | 2013-12-26 |