| NPI | 1790850121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: VA 2305001881) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126000016) |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2013-02-22 |