| NPI | 1467411736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NE 2904) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305204077) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126000725) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 334) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 555) | |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2011-09-13 |