| NPI | 1902856842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT0131046) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: PA DAPT000607) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT-001851-A) | |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2007-07-08 |