| NPI | 1669963583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 105668) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 092153) | |
| Enumeration Date | 2018-05-25 |
| Last Update Date | 2021-03-08 |