| NPI | 1003218447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: CT 10813) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 000803) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2022-02-06 |