| NPI | 1144730045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2000X Clinic/Center, Physical Therapy (Licence: ND 2496) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-10-05 |
| Last Update Date | 2021-06-21 |