| NPI | 1780039826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist, Orthopedic (Licence: WI 13958) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 10784) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2676) | |
| Enumeration Date | 2016-04-26 |
| Last Update Date | 2021-08-25 |