| NPI | 1982850871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: OR 62632) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: CT 008373) |
| Enumeration Date | 2008-08-12 |
| Last Update Date | 2020-01-06 |