| NPI | 1184127136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist Sports (Licence: MA PTL26067) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1249019) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT5955) | |
| 2251X0800X Physical Therapist Orthopedic (Licence: MA PTL26067) | |
| Enumeration Date | 2018-03-15 |
| Last Update Date | 2023-05-23 |