| NPI | 1104262617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: LA ATH.200132) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.200132) |
| Enumeration Date | 2013-05-13 |
| Last Update Date | 2025-05-01 |