| NPI | 1942971312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WV 004949) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV AT001719) |
| Enumeration Date | 2021-09-24 |
| Last Update Date | 2026-08-11 |