| NPI | 1205865706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225200000X Physical Therapy Assistant (Licence: MA 9002) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 923) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2014-11-07 |