| NPI | 1194209205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: FL 36267) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL 6080) |
| Enumeration Date | 2018-09-25 |
| Last Update Date | 2020-11-09 |