| NPI | 1710183025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2005028110) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2010017179) |
| Enumeration Date | 2007-06-23 |
| Last Update Date | 2013-12-06 |