| NPI | 1710185301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: VA 2305202418) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: WV 002567) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 050102053) | |
| Enumeration Date | 2007-07-05 |
| Last Update Date | 2025-01-10 |