| NPI | 1669757647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT010437) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001041) |
| Enumeration Date | 2011-10-20 |
| Last Update Date | 2022-05-25 |