| NPI | 1245750991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: UT 10408495-2401) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 10408495-4810) |
| Enumeration Date | 2017-06-23 |
| Last Update Date | 2023-11-03 |