| NPI | 1952789794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CA 295556) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MN 2000022201) |
| Enumeration Date | 2015-05-13 |
| Last Update Date | 2020-01-15 |