| NPI | 1720553597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MT PTP-PT-COM-JP-27111) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: ND 2529) |
| 225100000X Physical Therapist (Licence: MN 12946) | |
| 2255A2300X Specialist/Technologist Athletic Trainer | |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2023-09-25 |