| NPI | 1790366896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1341814) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: CO AT.0002708) |
| Enumeration Date | 2021-04-20 |
| Last Update Date | 2024-06-07 |