| NPI | 1184128506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225100000X Physical Therapist |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2022-04-01 |