| NPI | 1174135768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AL 1-1087) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 1839) |
| Enumeration Date | 2020-08-17 |
| Last Update Date | 2022-03-01 |