| NPI | 1508900465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC 2146) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NC 079102593-0234) |
| Enumeration Date | 2007-02-16 |
| Last Update Date | 2007-07-09 |