| NPI | 1679049514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IL 070.026917) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL BOC359051) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-10-18 |
| Last Update Date | 2022-10-18 |