| NPI | 1972610772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 119-039) |
| Enumeration Date | 2006-08-25 |
| Last Update Date | 2024-08-01 |