| NPI | 1285698068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT3024) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: TX 3204) |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2014-10-07 |