| NPI | 1356315105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO 114070) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 2007016208) |
| Enumeration Date | 2006-02-16 |
| Last Update Date | 2007-07-08 |