| NPI | 1679636245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL 22909) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 1377) |
| Enumeration Date | 2006-12-18 |
| Last Update Date | 2013-06-04 |