| NPI | 1558897322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 12014) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 3358) | |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2020-09-15 |