| NPI | 1154711398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO 15739) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 14228-24) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-01-26 |
| Last Update Date | 2021-04-28 |