| NPI | 1992161178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: GA PT014777) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096.004055) |
| Enumeration Date | 2016-01-04 |
| Last Update Date | 2020-08-20 |