| NPI | 1265575070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 9562) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CT 009799) |
| 2251S0007X Physical Therapist, Sports (Licence: WI 10590-024) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 783-039) | |
| Enumeration Date | 2007-02-14 |
| Last Update Date | 2020-08-11 |