| NPI | 1851583207 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT011778) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 6387) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT004164) | |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2022-04-28 |