| NPI | 1376180786 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 030926) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 001601) |
| Enumeration Date | 2019-12-04 |
| Last Update Date | 2019-12-04 |