| NPI | 1164597068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT004698) |
| Additional Taxonomies | 146M00000X Emergency Medical Technician, Intermediate (Licence: GA 32499) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT000379) | |
| Enumeration Date | 2006-11-24 |
| Last Update Date | 2025-09-11 |