| NPI | 1770011041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT025999) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 9393) |
| 225100000X Physical Therapist (Licence: OK 5491) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT005672) | |
| Enumeration Date | 2017-05-31 |
| Last Update Date | 2023-09-22 |