| NPI | 1316929151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MA 6229) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MA 6229) |
| 2251X0800X Physical Therapist, Orthopedic (Licence: MA 6229) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 217) | |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2007-07-08 |