| NPI | 1871972810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WV PT 003354) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL 28536) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV AT001360) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001666) | |
| Enumeration Date | 2015-05-22 |
| Last Update Date | 2015-05-22 |