| NPI | 1194276022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 62629) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OR 2000022059) |
| Enumeration Date | 2016-10-14 |
| Last Update Date | 2025-06-30 |