| NPI | 1407280779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 005289) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AZ 10478) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 001132) | |
| Enumeration Date | 2013-08-22 |
| Last Update Date | 2013-08-22 |