| NPI | 1144608084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 14697) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2255A2300X Specialist/Technologist Athletic Trainer | |
| Enumeration Date | 2015-05-12 |
| Last Update Date | 2021-06-15 |