| NPI | 1497266993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OR 63710) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OR 2000038059) |
| Enumeration Date | 2017-10-24 |
| Last Update Date | 2023-01-11 |