| NPI | 1568855534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MI 5501019972) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 15535-24) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2015-03-13 |
| Last Update Date | 2021-07-19 |