| NPI | 1861911760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IL 070026694) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WI 1964-39) |
| Enumeration Date | 2017-09-12 |
| Last Update Date | 2022-10-11 |