| NPI | 1336503390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 10977) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 4387) |
| Enumeration Date | 2016-04-06 |
| Last Update Date | 2018-03-08 |