| NPI | 1104921154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-00161) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: KS 11-02431) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2025-09-11 |