| NPI | 1174010797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 046250) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY P106547) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2018-04-19 |
| Last Update Date | 2020-09-21 |