| NPI | 1568673275 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 225200000X Physical Therapy Assistant (Licence: FL 33364) | 
| Additional Taxonomies | 225700000X Massage Therapist (Licence: FL MA36669) | 
| 2471C3402X Radiologic Technologist, Radiography (Licence: FL BMO83271) | |
| Enumeration Date | 2007-05-24 | 
| Last Update Date | 2025-03-20 |