| NPI | 1912940529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 9968-024) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2007-09-24 |