| NPI | 1265490858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT2660) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: OH PTA.06556) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2013-09-10 |