| NPI | 1306215835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: IL 070.026061) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-09-15 |
| Last Update Date | 2021-11-01 |