| NPI | 1871025544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KS 11-07789) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KS 24-01600) |
| Enumeration Date | 2017-03-31 |
| Last Update Date | 2025-01-13 |