| NPI | 1821021452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NE 2667) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 144) |
| Enumeration Date | 2006-07-08 |
| Last Update Date | 2022-11-01 |