| NPI | 1821158213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT012489L) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: DE J1-0001269) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2009-02-24 |