| NPI | 1811521925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AZ 034537) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 3562) |
| Enumeration Date | 2020-02-27 |
| Last Update Date | 2026-01-19 |