| NPI | 1659346229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 2039) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MN 1789) |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2015-03-18 |