| NPI | 1205351673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 092891) |
| Enumeration Date | 2017-08-07 |
| Last Update Date | 2021-01-21 |