| NPI | 1326499351 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2020022918) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO 2000025593) |
| Enumeration Date | 2016-06-30 |
| Last Update Date | 2021-03-30 |