| NPI | 1467565929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2001007779) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO 2001014038) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2008-01-17 |