| NPI | 1346613437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist, Sports (Licence: MN 12745) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36002462A) |
| Enumeration Date | 2015-11-11 |
| Last Update Date | 2022-07-06 |