| NPI | 1720306038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: OK 4809) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 437) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 820) | |
| Enumeration Date | 2010-05-11 |
| Last Update Date | 2014-12-03 |