| NPI | 1013427434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36001400A) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: IN 06004555A) |
| Enumeration Date | 2017-10-11 |
| Last Update Date | 2025-12-04 |