| NPI | 1780873745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: LA 100) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA 47) |
| Enumeration Date | 2007-10-16 |
| Last Update Date | 2007-10-16 |