| NPI | 1164821096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA PTL88664) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: RI PT03989) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA ATL3782) | |
| Enumeration Date | 2014-08-15 |
| Last Update Date | 2025-07-15 |