| NPI | 1740779057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 109035) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: MN 13311) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2018-05-02 |
| Last Update Date | 2024-11-14 |