| NPI | 1235160193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2001019657) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: MO 112536) |
| Enumeration Date | 2006-07-06 |
| Last Update Date | 2025-09-11 |