| NPI | 1700295565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 12598) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV 003362) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV 2000006008) | |
| Enumeration Date | 2014-08-06 |
| Last Update Date | 2020-09-29 |