| NPI | 1144539685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 624) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: OK 1021) |
| Enumeration Date | 2010-10-01 |
| Last Update Date | 2011-11-22 |