| NPI | 1265930291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 050616) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 003338) |
| Enumeration Date | 2018-01-24 |
| Last Update Date | 2023-08-15 |