| NPI | 1326436080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 10750-24) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 61039) |
| Enumeration Date | 2015-01-05 |
| Last Update Date | 2020-11-10 |