| NPI | 1083376172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL4532) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: FL MA94716) |
| Enumeration Date | 2021-10-06 |
| Last Update Date | 2021-10-06 |