| NPI | 1255959102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: VA 2305215797) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2020-07-08 |
| Last Update Date | 2023-05-30 |