| NPI | 1538504758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT5081) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: MO 2008003318) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2011008024) | |
| Enumeration Date | 2013-05-01 |
| Last Update Date | 2014-03-04 |