| NPI | 1386931673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AL PTH6169) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 915) |
| Enumeration Date | 2011-07-07 |
| Last Update Date | 2018-04-24 |