| NPI | 1245516400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: IA MD-48465) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT.003482) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MO 2017018413) | |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2021-04-13 |