| NPI | 1811930134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MS PT2745) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0383) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2012-04-08 |