| NPI | 1740488212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 62033539) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2007-07-06 |
| Last Update Date | 2019-01-31 |