| NPI | 1528786068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD 30610) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0001717) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT9070) | |
| Enumeration Date | 2022-08-19 |
| Last Update Date | 2025-11-03 |