| NPI | 1285151498 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 38355) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL 4267) | |
| Enumeration Date | 2017-08-28 |
| Last Update Date | 2024-06-25 |