| NPI | 1851025894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IA 123736) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IA 109070) |
| Enumeration Date | 2022-07-14 |
| Last Update Date | 2024-06-06 |