| NPI | 1154730992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2251S0007X Physical Therapist Sports (Licence: NC P13893) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NC LAT-2086) |
| Enumeration Date | 2014-08-06 |
| Last Update Date | 2014-08-06 |