| NPI | 1568479855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MD 21164) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MD 21164) |
| 2251X0800X Physical Therapist, Orthopedic (Licence: MD 21164) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2007-11-07 |