| NPI | 1396391520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 14815-24) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1754-39) |
| Enumeration Date | 2019-08-13 |
| Last Update Date | 2019-08-13 |