| NPI | 1073398012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: WI 17242-24) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 3261-39) |
| Enumeration Date | 2023-08-28 |
| Last Update Date | 2025-05-28 |