| NPI | 1295415867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ LPT-034167) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ ATR-009426) |
| Enumeration Date | 2023-07-19 |
| Last Update Date | 2025-05-22 |