| NPI | 1578247268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 42924) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ ATTL-000409) |
| Enumeration Date | 2023-06-13 |
| Last Update Date | 2025-04-16 |