| NPI | 1295463610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171400000X (Licence: AR 1210681743) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation Sports Medicine (Licence: AR 1210681743) |
| 2083S0010X Preventive Medicine Sports Medicine (Licence: AR 1210681743) | |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AR 1210644080) | |
| Enumeration Date | 2022-08-12 |
| Last Update Date | 2022-08-12 |