| NPI | 1376756288 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT1003) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: OH PTA011030) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2025-05-24 |