| NPI | 1841869880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 12291) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 3200) |
| Enumeration Date | 2021-06-23 |
| Last Update Date | 2024-02-01 |