| NPI | 1659962751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WA PT61122833) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A161143129) |
| Enumeration Date | 2021-02-01 |
| Last Update Date | 2021-02-01 |