| NPI | 1285006817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CT 12235) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 002102-01) |
| Enumeration Date | 2015-10-22 |
| Last Update Date | 2019-05-31 |