| NPI | 1861485377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: NC P19582) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT000999A) |
| 225100000X Physical Therapist (Licence: PA PT017416) | |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2020-06-10 |