| NPI | 1770173791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 17445-24) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 17343-24) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2021-01-23 |
| Last Update Date | 2025-08-12 |