| NPI | 1942679071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 3130581) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT7195) |
| Enumeration Date | 2015-09-18 |
| Last Update Date | 2023-05-12 |