| NPI | 1982015772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: KS 11-05637) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KS 24-00812) |
| Enumeration Date | 2014-05-14 |
| Last Update Date | 2020-06-18 |