| NPI | 1053662361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36001954A) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: IN 06006142A) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2021-01-07 |