| NPI | 1003467630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-09-25 |
| Last Update Date | 2024-05-22 |