| NPI | 1164946067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CA PT298784) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RTO000343) |
| Enumeration Date | 2017-08-01 |
| Last Update Date | 2020-09-09 |