| NPI | 1508492430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NJ 40QA02156700) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 048594) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 2MT002406000) | |
| Enumeration Date | 2020-03-23 |
| Last Update Date | 2023-05-04 |