| NPI | 1912989252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: IL 070004745) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096000735) |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2016-07-29 |