| NPI | 1336613199 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: ND 2650) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ND 2650) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2019-01-15 |
| Last Update Date | 2023-06-21 |