| NPI | 1144771817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: SD 2605) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: SD 0483) |
| Enumeration Date | 2016-10-18 |
| Last Update Date | 2023-04-21 |