| NPI | 1396265096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 10724) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: WI 14121) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2950) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1351) | |
| Enumeration Date | 2017-06-23 |
| Last Update Date | 2023-03-10 |