| NPI | 1780627083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 9563-24) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 9563024) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 279039) | |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2023-12-07 |