| NPI | 1184744716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305212445) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: DC PT872413) |
| 225100000X Physical Therapist (Licence: TX 1173220) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT2595) | |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2020-05-19 |