| NPI | 1073047759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: NC P20196) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC LAT-2888) |
| Enumeration Date | 2017-04-19 |
| Last Update Date | 2021-02-09 |