| NPI | 1912265455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 10441) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2344) |
| Enumeration Date | 2012-05-02 |
| Last Update Date | 2016-08-23 |