| NPI | 1376936484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501019284) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001743) |
| Enumeration Date | 2015-03-13 |
| Last Update Date | 2019-08-28 |