| NPI | 1639373574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OK 3077) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OK 431) |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2023-02-08 |