| NPI | 1962463653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IL 070014692) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096001542) |
| Enumeration Date | 2006-03-31 |
| Last Update Date | 2021-02-02 |