| NPI | 1861997421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ID PT-7264) |
| Additional Taxonomies | 225100000X Physical Therapist |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-27 |
| Last Update Date | 2023-02-22 |