| NPI | 1508384157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT26869) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305211521) |
| 225100000X Physical Therapist (Licence: OR 62868) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL2387) | |
| Enumeration Date | 2017-09-05 |
| Last Update Date | 2019-01-07 |