| NPI | 1265425920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 000012) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO R0321) |
| Enumeration Date | 2005-08-29 |
| Last Update Date | 2007-07-08 |