| NPI | 1780033969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2021038885) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2016024410) |
| Enumeration Date | 2016-06-08 |
| Last Update Date | 2021-09-28 |