| NPI | 1154802601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 078557) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: IA 54024) |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2018-08-23 |