| NPI | 1205218484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60554006) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A160180040) |
| Enumeration Date | 2015-06-23 |
| Last Update Date | 2015-06-23 |