| NPI | 1609081942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT 007647) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT 001133) |
| Enumeration Date | 2007-05-11 |
| Last Update Date | 2007-07-08 |