| NPI | 1831230382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: AL 1-0490) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: TN 8367) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 0888) | |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2016-08-22 |