| NPI | 1811225410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TN 7778) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: TN 07778) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 01075) | |
| Enumeration Date | 2009-11-20 |
| Last Update Date | 2017-03-07 |