| NPI | 1902218399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO CP043012T) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NY 043187) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 002559) | |
| Enumeration Date | 2014-05-20 |
| Last Update Date | 2025-03-20 |