| NPI | 1962663575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MO 2008023421) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO 2005028549) |
| Enumeration Date | 2008-06-17 |
| Last Update Date | 2014-10-17 |