| NPI | 1205235629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36001279A) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: IN 06003728A) |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2019-09-17 |