| NPI | 1639145980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA 6061) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 3025) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA 770) | |
| Enumeration Date | 2006-02-27 |
| Last Update Date | 2011-08-26 |