| NPI | 1053878736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: TX 1366114) |
| Enumeration Date | 2019-02-28 |
| Last Update Date | 2025-09-29 |