| NPI | 1164652582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NH 3386) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NH 0416) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 1524) | |
| Enumeration Date | 2009-07-20 |
| Last Update Date | 2009-07-20 |