| NPI | 1518480870 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: UT 9876846-2401) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: UT 9876846-8016) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 9876846-4810) | |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2022-08-16 |