| NPI | 1871593483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: ID PT-2077) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WA PT00009604) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-291) | |
| Enumeration Date | 2005-07-26 |
| Last Update Date | 2010-07-13 |