| NPI | 1639459332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2014031708) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2011030388) |
| Enumeration Date | 2011-08-25 |
| Last Update Date | 2017-02-09 |