| NPI | 1083604912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT005638) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: CA AT3715) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00043000) | |
| Enumeration Date | 2005-10-22 |
| Last Update Date | 2025-04-22 |