| NPI | 1053891697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: TX 1355844) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 23871) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT8902) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX 3599) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-08-14 |
| Last Update Date | 2022-11-25 |