| NPI | 1306559778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305215374) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003882) |
| 207PS0010X Emergency Medicine, Sports Medicine (Licence: VA 0126003882) | |
| 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: VA 2305215374) | |
| Enumeration Date | 2023-01-02 |
| Last Update Date | 2024-01-02 |