| NPI | 1225158124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT60618469) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: RI PT02430) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: RI AT00317) | |
| 225100000X Physical Therapist (Licence: CT 009687) | |
| Enumeration Date | 2007-04-02 |
| Last Update Date | 2016-03-04 |