| NPI | 1689668667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0012140) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: 6192) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 040402228) | |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2018-03-14 |