| NPI | 1629040977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT8414) |
| Additional Taxonomies | 2251S0007X Physical Therapist Sports (Licence: FL PT8414) |
| 2251X0800X Physical Therapist Orthopedic (Licence: FL PT8414) | |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL349) | |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2011-12-03 |