| NPI | 1013142884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: MO 2018003451) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2015028965) | |
| Enumeration Date | 2009-05-22 |
| Last Update Date | 2018-02-08 |