| NPI | 1740487339 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: SC 4311) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: SC 4311) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 496) | |
| Enumeration Date | 2007-06-28 |
| Last Update Date | 2016-05-18 |