| NPI | 1376566174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 4926-024) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 295-039) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2007-07-08 |