| NPI | 1639790090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 15111) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2020-04-27 |
| Last Update Date | 2025-09-27 |