| NPI | 1144361056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: MO 2009031662) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: IL 070011534) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2010039472) | |
| Enumeration Date | 2007-02-12 |
| Last Update Date | 2012-08-21 |