| NPI | 1609987650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 119668) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2008003299) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2012-07-13 |