| NPI | 1306900048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KS 11-04616) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KS 2400532) |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2013-06-12 |