| NPI | 1124139175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 847) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MA 16313) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2014-04-08 |