| NPI | 1174076285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: LA 09337R) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.200188) |
| Enumeration Date | 2016-07-26 |
| Last Update Date | 2016-07-26 |