| NPI | 1265767834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 05888) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT004181) |
| Enumeration Date | 2009-10-15 |
| Last Update Date | 2010-02-20 |