| NPI | 1083631840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 268-039) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 9516-024) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2025-09-11 |