| NPI | 1184128506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305215061) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: VA 0126003255) |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2025-07-14 |