| NPI | 1306364617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WV PT004414) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV 2000020739) |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2022-11-05 |