| NPI | 1720400062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC 1498) | |
| Enumeration Date | 2014-01-06 |
| Last Update Date | 2023-02-07 |