| NPI | 1578594792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: MN 5108) |
| Additional Taxonomies | 225100000X Physical Therapist |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2021-06-25 |