| NPI | 1740241611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 6042) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT 29055) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 3791) | |
| Enumeration Date | 2006-03-30 |
| Last Update Date | 2017-02-23 |