| NPI | 1659760189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT30000) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL PT30000) |
| Enumeration Date | 2015-01-21 |
| Last Update Date | 2015-02-06 |