| NPI | 1164782041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MS 5264) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0461) |
| Enumeration Date | 2012-05-24 |
| Last Update Date | 2014-07-21 |