| NPI | 1356463731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT4350) |
| Additional Taxonomies | 225400000X Rehabilitation Practitioner (Licence: TX AT4350) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2019-08-19 |