| NPI | 1548067713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NY 054064) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CA 300791) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 004947) | |
| Enumeration Date | 2025-02-26 |
| Last Update Date | 2025-09-20 |