| NPI | 1417040312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 0000006392) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 0000000634) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2015-02-02 |