| NPI | 1154535078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL pt22266) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: FL pt22266) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL al2121) | |
| Enumeration Date | 2007-05-09 |
| Last Update Date | 2007-07-08 |