| NPI | 1821075722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251X0800X Physical Therapist Orthopedic (Licence: AZ 8423) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CA PT 29611) |
| 2251S0007X Physical Therapist Sports (Licence: FL PT 21877) | |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL 1901) | |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2019-12-16 |