| NPI | 1508336405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: WI 15888-24) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 2305) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2018-12-04 |
| Last Update Date | 2024-05-02 |