| NPI | 1720115405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: FL PT10305) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: FL PT-0010305) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 1709) | |
| Enumeration Date | 2007-02-28 |
| Last Update Date | 2017-07-10 |