| NPI | 1841703691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT016761) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AL PTH10496) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2017-11-14 |
| Last Update Date | 2023-11-20 |