| NPI | 1174923643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WY 2002) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 2255A2300X Specialist/Technologist Athletic Trainer | |
| Enumeration Date | 2014-09-03 |
| Last Update Date | 2020-09-18 |