| NPI | 1326012568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist Sports (Licence: MO 119734) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO 119807) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2015-09-17 |